BJO Online First, published on November 3, 2016 as 10.
1136/bjophthalmol-2016-308948
Department of Ophthalmology
and Visual Sciences, Dalhousie
University, Halifax, Nova
Scotia, Canada
Correspondence to
Dr Marcelo Nicolela,
Department of Ophthalmology
and Visual Sciences, Dalhousie
University, 2W Victoria
Building, 1276 South Street,
Halifax (Nova Scotia) Canada
B3H 2Y9;
marcelo.nicolela@dal.ca
Received 28 April 2016
Revised 3 October 2016
Accepted 9 October 2016
To cite: Baril C, Vianna JR,
Shuba LM, et al. Br J
Ophthalmol Published
Online First: [ please include
Day Month Year]
doi:10.1136/bjophthalmol-
2016-308948
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
Clinical science
Rates of glaucomatous visual field change after
trabeculectomy
C Baril, J R Vianna, L M Shuba, P E Rafuse, B C Chauhan, M T Nicolela
ABSTRACT
Background Trabeculectomy is frequently performed in
patients with glaucoma who are deteriorating, although
its effects on rates of visual field (VF) progression are not
fully understood. We studied the rate of VF progression
post trabeculectomy comparing with medically treated
patients matched for VF loss.
Methods Medical records of patients who underwent
trabeculectomy alone or combined with cataract
extraction were reviewed. Patients with 5 or more 24–2
VF examinations post trabeculectomy were selected. The
rate of mean deviation (MD) change after surgery was
calculated for each patient. These patients were pairwise
matched based on baseline MD with patients with
glaucoma who were treated medically and had at least 5
VF tests.
Results 180 surgical patients were identified and
matched with 180 medically treated patients (baseline
MD of −8.72 (5.24) dB and −8.71 (5.22) dB,
respectively). Surgically and medically treated patients
were followed for 7.4 (2.9) and 6.8 (3.1) years
respectively. The MD slopes were −0.22 (0.55) dB/year
and −0.08 (1.10) dB/year in the surgically and medically
treated patients, respectively, and not statistically
different ( p=0.13, 95% CI −0.31 to 0.04). More
patients in the surgical group had fast progression (rates
worse than −1 dB/year) than in the medical group (17
and 7 patients, respectively, p=0.05).
Conclusions Our findings suggest that most patients
who undergo trabeculectomy demonstrate relatively slow
rates of VF progression postoperatively, similar to
patients treated medically, although some patients can
continue to progress despite adequate surgical control of
intraocular pressure.
INTRODUCTION
The main goal of glaucoma therapy is preservation
of the patient’s visual function, typically assessed
with visual field (VF) examination. Mean deviation
(MD) is a global measure that represents the overall
VF loss, compared with age-matched normal
values. The rate of MD deterioration over time has
been commonly used to express rate of disease pro-
gression in glaucoma.1–3 It is crucial to determine
the rate of change in a patient in order to detect
the severity of the disease progression and to
predict the likelihood of future functional
impairment.4
Trabeculectomy, enhanced with the application
of antimetabolite agents such as mitomycin C, is
the most commonly performed incisional surgery
for open angle glaucoma, when medical therapy is
insufficient to control the disease. The main indica-
tion for trabeculectomy is progression of VF
damage, although, in some cases, surgery could be
Baril C, et al. Br J Ophthalmol 2016;0:1–5. doi:10.1136/bjophthalmol-2016-308948
indicated prior to confirmed VF deterioration if the
intraocular pressure (IOP) is considered too high
for the stage of the disease.
Despite the many patients submitted to trabecu-
lectomy or similar surgical procedures for glau-
coma, the effect of trabeculectomy on the rate of
disease progression is not fully understood. Some
retrospective studies have shown less negative MD
slopes after surgery compared with before surgery,
although the rate of mean MD loss varied up to
threefold among the studies preoperatively (ranging
between −0.36 dB/year to −1.05 dB/year) and post-
operatively (ranging between −0.16 dB/year to
−0.49 dB/year).5–8 The variation of the results is
likely due to differences in the population studied,
study design and length of follow-up.
More importantly, studies without a predefined
protocol for confirmation of VF deterioration with
subsequent VF tests can be potentially affected by a
regression to the mean effect, due to the fact that
the decision to operate is not standardised and can
be triggered by a particularly poor VF. In these
cases, this poor VF test could cause a falsely steep
MD slope prior to surgery, which can be exacer-
bated by the anchoring effect of the last observation
on linear regression analysis.9 In this situation, a less
steep MD slope after surgery could be mistakenly
attributed to a treatment effect when, in fact, it
could be largely explained by a regression to the
mean effect.
In this present study we opted to use an alterna-
tive methodology for evaluating the effect of glau-
coma surgery on the rate of MD change, by
comparing it with the rate of VF loss in patients
with similar disease severity who did not undergo
surgery. This approach, which allows for an assess-
ment of the effects of trabeculectomy on VF pro-
gression without having to deal with the issue of
regression to the mean, was used in a recently pub-
lished study.10
MATERIALS AND METHODS
The study protocol was approved by the Nova
Scotia Health Authority Research Ethics Board and
adhered to the tenets of the Declaration of
Helsinki. Since it was a retrospective study,
informed consent was waived by the Research
Ethics Board.
Study population
Surgically treated patients
We retrospectively reviewed the charts of all
patients who underwent a first trabeculectomy or
combined cataract extraction and trabeculectomy
between January 1999 and December 2012 by one
of three glaucoma surgeons (MTN, LMS, PER) at
1
 Clinical science
the Queen Elizabeth II Health Sciences Centre in Halifax, Nova
Scotia, Canada. To ensure that the MD rates were based on a
reasonable number of VF examinations, only patients with five
or more SITA-Standard 24–2 Humphrey Field Analyzer (Carl
Zeiss Meditec, Dublin, California, USA) VF examinations after
surgery were included in the analysis. If both eyes of a patient
fulfilled the inclusion criteria, one eye was randomly selected
for analysis. The first postsurgery VF test was defined as the
baseline examination for these patients.
Laser suture lysis, bleb needling, antimetabolite subconjuncti-
val injection, topical and/or systemic glaucoma medication and
surgical revision were used during the postoperative period
when clinically indicated and were not considered exclusion cri-
teria. However, eyes that underwent a subsequent glaucoma sur-
gical procedure (second trabeculectomy, glaucoma drainage
device implantation, cyclophotocoagulation or any other surgi-
cal glaucoma procedure) were excluded from the study.
Medically treated patients
Each surgically treated patient was matched by baseline MD to
a patient treated by topical medical therapy (with or without
the additional use of laser trabeculoplasty) who had at least five
SITA-Standard 24–2 VF tests. These medically treated patients
were extracted from a large database of patients with glaucoma
treated in our centre1 and were managed clinically throughout
the whole follow-up, without ever having a surgical glaucoma
procedure. Similarly, in this group, if both eyes from the same
patient fulfilled the inclusion and exclusion criteria, only one
eye was randomly selected for analysis.
Patients in either group with any other ocular or non-ocular
disease known to cause VF defects were excluded. No patient
contributed with both eyes in the study (with one in each
group).
Data collection
Parameters collected from the clinical charts included age,
gender, type of glaucoma, refraction, axial length, preoperative
glaucoma laser procedures, lens status, visual acuity, IOP and
ocular hypotensive medications. In the surgically treated eyes,
preoperative IOP was calculated as the mean of the three most
recent values measured prior to surgery; in this group we
excluded from the analysis the IOP values measured during the
first 2 months after surgery, due to the possibility of large IOP
fluctuations in the immediate postoperative period.
Statistical analysis
The rate of MD change was calculated for each patient with
robust regression analysis. Robust regression is a technique that
provides slope estimates that are more resistant to outlier obser-
vations.11 Patients with MD slopes < −1 dB/year were classified
as fast progressors.1 We compared the average MD slopes in
both groups with a paired t-test and the number of patients
with fast progression using the Fisher’s exact test.
Statistical analysis was carried out in the open-source pro-
gramming language R. (R Foundation for Statistical Computing,
V.3.2.0), using package ‘robustbase’ (V.0.92–3).
RESULTS
During the 14-year-period we evaluated, trabeculectomy and/or
combined cataract extraction and trabeculectomy surgery were
performed in 4135 eyes. Due to the tertiary nature of our
clinic, serving a very large geographical referring area, the vast
majority of our surgical patients are followed after surgery by
their referring ophthalmologist and, therefore, we did not have
2 Baril C, et al. Br J Ophthalmol 2016;0:1–5. doi:10.1136/bjophthalmol-2016-308948
enough postoperative VF information for these patients.
Accordingly, we identified 180 surgical eyes from 180 patients
who met all the inclusion and exclusion criteria, which were
matched by baseline MD to 180 medically treated eyes.
In the surgically treated group, 86 eyes (47.8%) underwent
trabeculectomy alone and 94 eyes (52.2%) underwent combined
cataract extraction and trabeculectomy. The mean (±SD) time
from surgery to first (baseline) VF was 0.8 (±1.0) years.
The mean baseline MD (±SD) in the surgically and medically
treated groups was −8.72 (±5.24) dB and −8.71 (±5.22) dB,
respectively ( p=0.38). The mean (SD) unsigned difference in
baseline MD within matched pairs of surgically and medically
treated patients was 0.04 (±0.09) dB. Demographics of the
patients and characteristics of the study eyes are shown in table 1.
Surgically treated patients had significantly more VF tests com-
pared with medically treated patients (10.8 and 8.4, respectively,
p<0.01). There was also a trend for longer follow-up time in the
surgically treated eyes compared with the medically treated eyes
(7.4 years and 6.8 years, respectively, p=0.05).
There was no statistically significant difference in the mean
MD slopes between the two groups: −0.22 (±0.55) dB/year
postoperatively in the surgically treated patients, and −0.08
(±1.10) dB/year in the medically treated patients ( p=0.13, 95%
CI of the mean difference: −0.31 to 0.04). Figure 1 shows the
distribution of the MD slopes in the two groups. In the medical
and surgical group, respectively, 7 (3.9%) and 17 (9.4%)
patients were classified as fast progressors ( p=0.05). There was
no statistically significant difference ( p=0.10) in the MD slopes
of the patients who underwent combined cataract extraction
and trabeculectomy (−0.27±0.50 dB/year) or trabeculectomy
alone (−0.17±0.60 dB/year). Figure 2 shows the MD slopes as a
function of the baseline MDs in both groups, suggesting no dif-
ference between the groups in any range of severities.
Surgically treated patients were using a mean of 2.5 (±1.0)
topical medications before surgery, which was reduced to 0.9
(±1.1), at the last follow-up visit post surgery ( p<0.01, paired
t-test). Their mean IOP before surgery was 19.8 (±7.5) mm Hg,
which was reduced to 12.0 (±4.4) mm Hg at the last follow-up
visit post surgery ( p<0.01, paired t-test). The mean and
minimum IOPs were significantly lower and IOP fluctuation
(maximum IOP−minimum IOP) was significantly higher in the
surgically treated group postoperatively compared with the med-
ically treated group. Details of IOP parameters in the two
groups can be found in table 2.
The mean IOP of patients with fast progression was 12.7
(±2.4) mm Hg and 17.6 (±3.9) mm Hg in the surgically
Table 1 Demographics and clinical information from the surgically
and medically treated patients (p values determined by paired
t-test)
Surgically treated Medically treated
patients patients
n=180 patients n=180 patients
(eyes) (eyes)
Mean (±SD) Mean (±SD)
Baseline MD (dB) −8.72 (±5.24) −8.71 (±5.22) p=0.38
Age (years) 69.7 (±10.7) 67.2 (±14.4) p=0.08
Number of visual 10.8 (±4.3) 8.4 (±3.7) p<0.01
field tests
Follow-up (years) 7.4 (±2.9) 6.8 (±3.1) p=0.05
dB, decibels; MD, mean deviation.

Figure 1 Distribution of the MD
slopes in the surgically (n=180 eyes)
and medically (n=180 eyes) treated
patients. MD, mean deviation;
dB, decibels.
(n=17) and medically (n=7) treated patients, respectively. In
the surgical cohort, mean IOP in the non-fast progressors
(n=163) was 12.1 (±3.5) mm Hg, similar to the IOP observed
in the fast progressors ( p=0.46). There was no statistically sig-
nificant difference in baseline MDs between the fast progressors
compared with the non-fast progressors in both the surgically
and medically treated patients ( p=0.82 and 0.29, respectively).
Results are summarised in table 3.
DISCUSSION
The main goal of our study was to evaluate if successful trabecu-
lectomy or combined cataract extraction and trabeculectomy
would prevent further VF progression. In order to avoid the
possibility of a regression to the mean effect, we compared our
rates of progression post surgery with a control group matched
by baseline MD and composed of patients who were treated
medically, without ever having glaucoma surgery. A similar
approach was used by Caprioli et al10 in a recently published
manuscript.
We found that the rate of VF progression in the surgically
treated patients was similar to that observed in medically treated
Figure 2 MD slopes as a function of
the baseline MD in surgically and
medically treated patients. MD, mean
deviation; dB, decibels.
Baril C, et al. Br J Ophthalmol 2016;0:1–5. doi:10.1136/bjophthalmol-2016-308948
Clinical science
patients: −0.22 dB/year and −0.08 dB/year, respectively.
However, more patients in the surgical group showed fast VF
progression (rates worse than −1 dB/year) than in the medically
treated group (17 and 7, respectively), a difference that
approached statistical significance.
Although it is difficult to compare across different studies,
our results in the surgical group are in the range of MD loss
reported after glaucoma surgery: Bertrand et al5 and Folgar
et al6 observed a mean MD change after surgery of −0.16 dB/
year in 52 eyes and −0.49 dB/year in 74 eyes, respectively. In
eyes with progressive normal tension glaucoma, Iverson et al7
and Shigeeda et al8 reported mean postoperative MD change of
−0.25 dB/year and −0.44 dB/year respectively, compared with
−1.05 dB/year preoperatively in both cohorts. In a recent study
by Caprioli et al,10 the mean decay rate (measured by the VF
index) in patients who underwent trabeculectomy slowed from
−2.4±9.3%/year preoperatively to −0.6±13.1% after surgery.
Elevated IOP has been confirmed as a significant risk factor
for glaucoma progression in many landmark studies.12–17 In our
study, as expected, the surgically treated eyes had significantly
lower mean IOP postoperatively than the medically treated
3
 Clinical science

surgically treated patients were followed for a longer period of

Table 2 Intraocular pressure (IOP) characteristics in surgically and
medically treated patients during follow-up period (only period after
surgery was considered for the surgically treated patients; p values
determined with paired t-test)
Surgically treated Medically
group treated group
n=180 eyes n=180 eyes
Mean (±SD) Mean (±SD)
Mean IOP 12.1 (±3.4) 16.3 (±3.5) p<0.01
Minimum IOP 7 (±3.3) 14 (±3.5) p<0.01
Maximum IOP 18 (±6.7) 20 (±5.2) p=0.16
IOP fluctuation 10 (±7.0) 6 (±4.5) p<0.01
IOP fluctuation, maximum IOP−minimum IOP.
group, but both groups showed similar rates of MD progression.
It is likely that in our study the surgically treated patients had
higher risk for disease progression than the medically treated
patients, hence the indication for surgery in the first place.
Therefore, the lower mean IOP in the surgical group could have
accounted for the equal rates of VF loss in the two groups.
Another possible explanation for the equal rates of VF loss
despite significantly lower IOP in the surgical group is that the
beneficial effects of lower IOP are not observed across the
whole spectrum of IOP, meaning that once the IOP is already
reduced significantly, there is no additional benefit from further
IOP reduction. The results from the Collaborative Initial
Glaucoma Treatment Study, which was the largest randomised
study comparing initial surgical and medical treatments, seems
to suggest this possibility: in that study, patients randomised to
surgical treatment had significantly lower mean IOP but similar
levels of VF progression when compared with patients rando-
mised to medical treatment.18
We observed a large range of MD change over time in both
the surgically and medically treated groups. Even though the
majority of patients from the two groups had slow rates of
change, some patients had fast progression, more frequently in
the surgically treated group. Several studies have shown that
even successful trabeculectomy fails to halt fast VF deterioration
in all patients.8 19–22 It is interesting to note that in the surgi-
cally treated group, patients who showed fast progression had
similar baseline VF damage and similar postoperative IOP than
patients with more stable VF, suggesting that other factors pre-
disposed those patients to more rapid VF deterioration.
The chances of detecting VF change increase with longer
follow-up time and MD rates are more precise if a greater
number of VF examinations are performed.23 In our study, the
time and had more VF examinations than the medically treated
patients, which could have affected our results. We explored this
possibility by repeating our analyses in censored subsets of data,
omitting the last fields in one of each pair of eyes according to
shortest length of follow-up or to smallest number of fields.
This analysis provided results similar to those reported, suggest-
ing that longer follow-up time and more VF tests in the surgical
group did not affect our results.
Worse baseline VF damage has been identified as a risk factor
for VF progression in many studies,15 17 24 which is why we
matched our two groups by the baseline MD. Apart from being
well matched in terms of baseline MD, our two groups were
also matched by baseline age, which has also been identified as a
significant risk factor for progression.2 13 15 18 25 Another
strength of our study is the large number of eyes in the two
groups and the relatively long follow-up of approximately
7 years in both groups.
Our study has some limitations: Due to its retrospective
nature, it is likely that the risk profile of our two studied popu-
lations was different: the surgically treated patients were likely
considered by their attending physician to be at high risk of pro-
gressing, or already progressing, prior to surgery; on the other
hand, patients managed with medical therapy were likely
thought to be stable, making comparisons between the two
groups open for interpretations. If anything, our study design is
biased to show more rapid progression in the surgically treated
patients, and the fact the mean MD rates of the two groups
were not statistically significant reinforces our conclusion that
successful glaucoma surgery has a positive impact in the
outcome of most patients with glaucoma.
Despite the lack of statistical significance, our results may
indicate that the expected rates in the post-trabeculectomy
group are faster than in the medically treated group, but this dif-
ference is estimated to be less than −0.31 dB/year, which may
still be considered a slow rate of progression.
Another possible criticism is that we excluded patients who
had subsequent glaucoma surgery in our surgical group, and
therefore might have excluded patients who were progressing
after the initial surgery, which could affect our reported rates.
Most times, however, the indication for a second glaucoma
surgery is due to surgical failure with elevation of IOP to the
presurgery values or higher. In those cases we typically don’t
wait for further progression before proceeding to a second
surgery. Since the main goal of our study was to evaluate if suc-
cessful glaucoma surgeries lead to preservation of visual func-
tion, we felt it was necessary to exclude patients who were
submitted to a second glaucoma operation.

Table 3 Baseline mean deviation (MD) and mean follow-up intraocular pressure (IOP) characteristics in fast progressors (MD < −1 dB/year)
compared with non-fast progressors in surgically and medically treated patients (p values determined with Mann-Whitney U test)
Baseline MD (dB) IOP (mm Hg)
Mean (±SD) Mean (±SD)

Surgically treated group Non-fast progressors −8.76 (±5.25) p=0.82 12.1 (±3.5) p=0.46
n=163 eyes
Fast progressors −8.34 (±5.23) p=0.29 12.7 (±2.4)
n=17 eyes
Medically treated group Non-fast progressors −8.64 (±5.24) 16.6 (±3.5) p=0.73
n=173 eyes
Fast progressors −10.38 (±4.47) 17.6 (±3.9)
n=7 eyes
dB, decibels.

4 Baril C, et al. Br J Ophthalmol 2016;0:1–5. doi:10.1136/bjophthalmol-2016-308948


CONCLUSION
Our findings suggest that most patients who undergo successful
trabeculectomy or combined cataract extraction and trabeculect-
omy have slow rates of VF progression, with average rates
similar to those observed in medically treated patients. It is
likely that the low IOP obtained after surgery halted further VF
progression in this group of patients. However, more patients in
the surgical group (9.4%) showed fast progression compared
with the medical group (3.9%), despite very adequate surgical
IOP control, suggesting that other factors might be contributing
to VF progression in this subset of patients.
Acknowledgements The authors thank Anne Belliveau.
Contributors All authors (CB, JRV, LMS, PER, MTN, BCC) have made substantial
contributions to the conception of the work and the acquisition, analysis and
interpretation of the data; drafting the work and/or revising it critically. All authors
have granted final approval of this revised version to be published and agree to be
accountable for all aspects of the work in ensuring that questions related to the
accuracy or integrity of any part of the work are appropriately investigated and
resolved.
Competing interests None declared.
Ethics approval Nova Scotia Health Authority Research Ethics Board.
Provenance and peer review Not commissioned; externally peer reviewed.
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